PRACTICAL THERAPEUTICS

Promoting and Prescribing Exercise

for the Elderly
ROBERT J. NIED, M.D., Michigan State University, East Lansing, Michigan
BARRY FRANKLIN, PH.D., William Beaumont Hospital, Royal Oak, Michigan
Regular exercise provides a myriad of health benefits in older adults, including improvements in blood pressure, diabetes, lipid profile, osteoarthritis, osteoporosis, and
neurocognitive function. Regular physical activity is also associated with decreased
mortality and age-related morbidity in older adults. Despite this, up to 75 percent of
older Americans are insufficiently active to achieve these health benefits. Few contraindications to exercise exist, and almost all older persons can benefit from additional
physical activity. The exercise prescription consists of three components: aerobic exercise, strength training, and balance and flexibility. Physicians play a key role in motivating older patients and advising them regarding their physical limitations and/or
comorbidities. Motivating patients to begin exercise is best achieved by focusing on individual patient goals, concerns, and barriers to exercise. Strategies include the stages of
change model, individualized behavioral therapy, and an active lifestyle. To increase
long-term compliance, the exercise prescription should be straightforward, fun, and
geared toward a patients individual health needs, beliefs, and goals. (Am Fam Physician
2002;65:419-26,427-8. Copyright 2002 American Academy of Family Physicians.)

Members of various
medical faculties
develop articles for
Practical Therapeutics. This article is one
in a series coordinated
by the Department of
Family Medicine at the
University of Michigan
Medical School, Ann
Arbor. Guest editor of
the series is Barbara S.
Apgar, M.D., M.S.,
who is also an associate editor of AFP.

egular exercise has been shown

to decrease mortality and agerelated morbidity in older
adults.1-3 Despite this, up to
three fourths of the older adult
population do not currently exercise at recommended levels. The relative risk (RR) for
cardiovascular disease caused by sedentary
living has been estimated to be 1.9, compared
with other modifiable risk factors such as
hypertension (RR = 2.1) and cigarette smoking (RR = 2.5), but it occurs at a much higher
prevalence.4 Fewer than 10 percent of women
over age 75 smoke cigarettes while greater
than 70 percent are insufficiently active.5
By the year 2030, 22 percent of the U.S. population will be older than 65 years, a total of 70
million people.6 The fastest growing segment of
the elderly population is the group older than
85 years, classified as old old. Because activity
levels generally decline with advancing age, the
absolute number of inactive older Americans
will most likely increase dramatically.
As the population of older adults increases,
it will become vitally important for family
physicians to counsel sedentary patients to
become physically active.

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O A patient information handout on exercise for the elderly,

written by the authors
of this article, is provided on page 427.

Benefits of Exercise
As is the case in younger adults, regular exercise has been shown to provide a myriad of benefits in older adults (Table 1).1 Improvements in
cardiovascular, metabolic, endocrine, and psychologic health are well documented.1,7-9 Cardiovascular fitness, although not directly correlated with health benefits, is a determinant of
functional independence.10 Up to one third of
the age-related decline in aerobic capacity
(VO2 max) can be reversed with prolonged (six
months or more) aerobic training.1
Regular exercise and/or increased aerobic
fitness are associated with a decrease in allcause mortality and morbidity in middleaged and older adults.2,3 Subgroup analysis of
the Harvard Alumni study found that modest
increases in life expectancy were possible even
in those patients who did not begin regular
exercise until age 75.11 Mortality rates were
also lower in those patients who did not begin
regular exercise until late in life compared
with patients who were active only in younger
years and then subsequently stopped exercising.11 Thus, it is never too late for patients to
benefit from physical activity.
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TABLE 1

Benefits of Exercise in Older Adults

Cardiovascular
Improves physiologic parameters
(VO2 max, cardiac output, decreased
submaximal rate-pressure product)
Improves blood pressure
Decreases risk of coronary artery disease
Improves congestive heart failure
symptoms and decreases
hospitalization rate
Improves lipid profile
Diabetes mellitus, type 2
Decreases incidence
Improves glycemic control
Decreases hemoglobin A1C levels
Improves insulin sensitivity

Osteoporosis
Decreases bone density loss in postmenopausal women
Decreases hip and vertebral fractures
Decreases risk of falling

Cancer
Potential decrease in risk of colon, breast,
prostate, rectum
Improves quality of life and decreases
fatigue

Osteoarthritis
Improves function
Decreases pain

Other
Decreases all-cause mortality
Decreases all-cause morbidity
Decreases risk of obesity
Improves symptoms in peripheral
vascular occlusive disease

Neuropsychologic health
Improves quality of sleep
Improves cognitive function
Decreases rates of depression, improves
Beck depression scores.
Improves short-term memory

The health benefits of exercise follow a

hyperbolic dose-response curve. Those patients who go from none to some exercise
receive the greatest health benefits, while further increases in activity levels bring progressively smaller improvements.12 Physicians can
have the greatest overall impact by helping
their sedentary patients to become active.
Illustrative Cases
CASE 1

A 71-year-old man who has moderately

well-controlled hypertension, and osteoarthritis of the knees bilaterally and right hip.
He is active in two bowling leagues and enjoys
walking; however, both activities are becoming limited by pain in his knees.
He will benefit from increasing the level

The Authors
ROBERT J NIED, M.D., is currently in private practice with Mission Medical Associates,
San Luis Obispo, Calif. Dr. Nied received his medical degree from the University of California, Los Angeles School of Medicine. He completed a residency in family medicine
at the University of Michigan, Ann Arbor, and recently completed a fellowship in sports
medicine at Michigan State University, East Lansing.
BARRY FRANKLIN, PH.D., is the director of the Cardiac Rehabilitation and Exercise
Laboratories, William Beaumont Hospital, Royal Oak, Mich., and professor of physiology at Wayne State University School of Medicine, Detroit. He earned his doctorate in physiology from Penn State University, University Park, Pa. He is the immediate past president of the American College of Sports Medicine and serves on the
editorial board of the American Journal of Cardiology, the Journal of Cardiopulmonary Rehabilitation, the American Journal of Health Promotion, and Physician
and Sportsmedicine.
Address correspondence to Robert J. Nied, M.D., Mission Medical Associates, 1235
Osos St., San Luis Obispo, CA 93401. Reprints are not available from the authors.

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of activity and incorporating resistance

training into his exercise routine. The patient
began cross training with nonweight-bearing activities of swimming and biking three
times per week. He was encouraged to wear
good athletic shoes and may benefit from
bracing, orthotics, nonsteroidal anti-inflammatory medication, or viscosupplementation. A twice-weekly, resistance training program was initiated focusing initially on lower
extremity strength using light weights on a
multipurpose machine.
CASE 2

An 85-year-old woman who lives alone has

a previous history of a minor stroke and has
hypertension controlled with a beta blocker.
She does not have known osteoporosis or a
history of fracture and is currently sedentary.
On examination, this patient had some difficulty with eyes-closed balance and was
unable to stand from a chair without using
both armrests, indicating fairly significant leg
weakness. She began her exercise program
by focusing on balance and strength with a
simple home routine based on chair exercises,
12 oz soup cans, and balancing on one leg
while holding the kitchen counter. Because
she is asymptomatic for coronary artery disease, she can begin a low-intensity aerobic
program without further testing. Because of
the cold weather, the patient chose to begin
walking the ground floor of her large apartment building, adding time and distance as
she gains endurance.
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Exercise for the Elderly

Strength Training
Although the positive benefits of aerobic
exercise are widely accepted, the importance
of resistance training in the older population
has also become increasingly apparent. Muscle
strength declines by 15 percent per decade
after age 50 and 30 percent per decade after
age 70.1 This is principally the result of sarcopenia (loss of muscle mass) and occurs to a
greater degree in older women than men.
Results from the Framingham disability
study13 demonstrate that 45 percent of
women older than 65 years and 65 percent
older than 75 years cannot lift 10 lb. Resistance
training can result in 25 to 100 percent, or
more, strength gains in older adults through
muscle hypertrophy and, presumably,
increased motor unit recruitment.1,14
Strength is intrinsic to daily function, especially in the very elderly. Most of the variance
in walking speed in the elderly is related to leg
strength, and increased strength has been
shown to improve walking endurance and
stair-climbing power. Strength training also
improves nitrogen balance and can, combined
with adequate nutrition, prevent muscle wasting in institutionalized elderly persons.14,15
The rise in heart rate and blood pressure
with resistance work is largely proportional to
the percent of maximal voluntary contraction
(MVC). Consequently, minimal lifting (e.g.,
routine housework) can produce a dramatic
rise in the rate-pressure product in weak,
elderly patients. In addition to absolute
strength gains, resistance training attenuates
the cardiac demands of any given load
because the load now represents a lower percentage of the MVC.16

Muscle strength declines by 15 percent per decade after age

50 and 30 percent per decade after age 70; however, resistance training can result in 25 to 100 percent, or more,
strength gains in older adults.

contraindications to aerobic exercise or resistance training (Table 2).1,16 Even patients with
these conditions can safely exercise at low levels once appropriate evaluation and treatment have been initiated. For example, early
exercise-based cardiac rehabilitation has become a mainstay of postmyocardial infarction care. The 26th Bethesda Conference
guidelines17 contain specific recommendations for patients with hypertension, valvular,
and other cardiovascular disease.
Simple office tests for cardiovascular fitness and global strength have been
described.18,19 While these tests may be useful
in following a patients progress, they are
generally not necessary for the initial exercise
prescription. A resting office-based electro-

TABLE 2

Potential Contraindications to Aerobic Exercise

and Resistance Training
Absolute

Relative

Recent ECG change or myocardial infarction

Unstable angina
Third-degree heart block
Acute congestive heart failure
Uncontrolled hypertension
Uncontrolled metabolic disease

Cardiomyopathy
Valvular heart disease
Complex ventricular ectopy

Preparticipation Screening

ECG = electrocardiogram.

HISTORY AND PHYSICAL

Adapted with permission from American College of Sports Medicine Position

Stand. Exercise and physical activity for older adults. Med Sci Sports Exerc
1998;30:992-1008, and Pollock ML, Franklin BA, Balady GJ, Chaitman BL, Fleg
JL, Fletcher B, et al. AHA Science Advisory. Resistance exercise in individuals with
and without cardiovascular disease: benefits, rationale, safety, and prescription.
Circulation 2000;101:828-33.

Before initiating an exercise program, most

older adults should undergo a history and
physical examination directed at identifying
cardiac risk factors, exertional signs/symptoms, and physical limitations. There are few
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TABLE 3

Guidelines for Cardiac Stress Testing

Men 45 years and women 55 years who plan
to exercise at 60 percent VO2 max
Known coronary artery disease or cardiac symptoms
Two or more coronary artery disease risk factors*
Diabetes
Known or major signs/symptoms of pulmonary or
metabolic disease
*Hypertension, smoking, hypercholesterolemia,
obesity, sedentary lifestyle, family history of early
coronary artery disease.
Adapted with permission from Franklin BA, Whaley
MH, Howley ET, eds. ACSMs guidelines for exercise
testing and prescription. 6th ed. Baltimore: Lippincott Williams & Wilkins, 2000.

cardiogram (ECG) has limited use in preparticipation screening. Bradycardia, minor

ST-wave changes, and atrial and ventricular
complexes can be normal variants in older
persons and are nonspecific for coronary
artery disease.

TABLE 4

Recommended Levels of Physical Activity

Cardiovascular
Moderate aerobic activity for a combined total of at least 30 minutes, most
days of the week.* Individual bouts of activity may be as brief as 10 minutes.
Strength training
A single set of 10 to 15 repetitions using eight to 10 different exercises, performed
two to three times per week. Each repetition should be performed slowly
through a full range of motion while avoiding holding ones breath (Valsalva
maneuver). The training program should involve all major muscle groups.
Balance and flexibility
Stretch major muscle groups once per day after exercise when muscles are more
compliant. Balance training and weight transfer program twice per week.
*For most older adults, moderate activity corresponds to 2.5 to 5.5 metabolic
equivalents, equivalent to level walking at a 2.0 to 4.5 mph pace.
Clinically relevant muscle groups include hip extensors, knee extensors, ankle
plantar flexors and dorsiflexors, biceps, triceps, shoulders, back extensor, and
abdominal muscles.
Stretches should be performed in a stretch and hold fashionavoid ballistic or bouncing stretches.
Supervised and progressively more difficult postural exercises that either
reduce the base of support (e.g., one-leg stands), perturb the center of gravity
(e.g., circle turns), stress postural muscles (e.g., heel stands), or reduce other sensory input (e.g., vision).
Adapted with permission from American College of Sports Medicine Position
Stand. Exercise and physical activity for older adults. Med Sci Sports Exerc
1998;30:992-1008.

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EXERCISE STRESS TESTING

The American College of Sports Medicine

recommends exercise stress testing for all
sedentary or minimally active older adults who
plan to begin exercising at a vigorous intensity
(Table 3).20 Most elderly patients, however, can
safely begin a moderate aerobic and resistance
training program without stress testing if they
begin slowly and gradually increase their level
of activity. A community-based walking program in Massachusetts involving almost 8,000
elderly patients reported no incidence of
myocardial infarction or other adverse cardiac
events during exercise over an eight-year
period.21 Patients should be counseled to discontinue exercise and seek medical advice if
they experience major warning signs or symptoms (e.g., chest pain, palpitations, or lightheadedness).
Exercise stress testing can also be used to determine a patients fitness level, generally expressed as metabolic equivalents (METs; one
MET = 3.5 mL O2 per kg per minute), and to
define an appropriate range of exercise intensity.
The Exercise Prescription
The exercise prescription consists of three
components: aerobic exercise, strength training, and balance and flexibility (Table 4).1
Specific exercise recommendations for a
given patient will depend on existing comorbidities and on the baseline level of physical
activity. Initially, sedentary patients should
begin at a very low level and gradually progress to a goal of moderate activity. Moderate
activity can be defined using heart rate and
VO2 max ranges, rating of perceived exertion,
and MET charts for specific activities
(Table 5).12 More simply, patients should exercise at the maximal intensity at which they are
still able to comfortably carry on a conversation (the talk test). This may require some
trial and error for patients. Warm-up and
cool-down periods consisting of five to 10
minutes of less intense activity (e.g., slow
walking, stretching) should be included to
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Exercise for the Elderly

TABLE 5

Activities Requiring Moderate

Intensity Exercise*
Walking briskly (3 to 4 mph)
Cycling leisurely ( 10 mph)
Swimming with moderate effort
Doubles tennis
Golfusing a pull cart
Fishingstand and cast
Canoeing leisurely (2 to 4 mph)
Mowing lawn with a power mower
Home repair, painting
mph = miles per hour
*Moderate intensity defined as 3.0 to 6.0 metabolic equivalents or 4 to 7 kcal per minute and
slightly lower (i.e., 2.5 to 5.5 metabolic equivalents)
for older adults.
Adapted with permission from Pate RR, Pratt M,
Blair SN, Haskell WL, Macera CA, Bouchard C, et al.
Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-7.

decrease the risk of hypotension, and musculoskeletal and cardiovascular complications.

As in aerobic exercise, initially sedentary or
irregularly active older adults beginning resistance training should start slowly and gradually advance the intensity of their training
regimen. Patients should start with resistive
bands/tubing, light weights (e.g., 2 lb hand
weights or a can of food), or simple exercises
such as repeatedly rising from a chair.
Although health benefits are achievable with
less intense training, significant strength gains
require patients to train at an intensity in
which they can complete 10 to 15 repetitions
per set before reaching fatigue. Training needs
to be progressively more intense with increasing weight to continue to derive additional
strength gains and, possibly, to prevent the
long-term loss of previous strength gains.22
The evidence for balance and flexibility
training is inconclusive. Nevertheless, empiric
evidence suggests that balance programs,
such as repeatedly standing on one leg, can
improve stability and decrease the risk of
falls.1 Deconditioned and sedentary elderly
patients should be encouraged to improve
their functional ability with strength and balance training before beginning aerobic exerFEBRUARY 1, 2002 / VOLUME 65, NUMBER 3

Exercise prescription for older adults consists of aerobic exercise, strength training, and balance and flexibility.

cise. A physical therapist can be helpful in

identifying physical limitations and designing
a specific exercise routine. Personal trainers
or other athletic club personnel also may be
helpful for relatively healthy patients who are
already generally active. Trained geriatric
exercise leaders are becoming increasingly
common at health clubs and senior centers.
The complete exercise prescription, as demonstrated by the Activity Pyramid (Figure 1),
includes increased daily activities and regular
aerobic, resistance, and balance exercises.
Any exercise prescription, however, is a
dynamic process that should be structured to
fit an individual patients current goals and
comorbidities and be responsive to changes
over time.
Promoting Physical Activity
In addition to helping patients to exercise
safely, physicians also play an important role
in promoting increased activity, especially in
older patients.23 The strength of physicians
advice is significantly correlated with the likelihood of adopting increased physical activity
in older cardiac patients.24
There are many approaches to exercise promotion available for physicians. The stages of
change model is often used to promote a
range of positive behaviors.25 Attempts to formalize this model for exercise promotion have
met with moderate success.26 Computer templates interacting directly with patients to create tailored messaging is a new focus, and several Web sites with specific exercise programs
for adults are available. Many older patients,
however, will require individualized counseling because of specific physical limitations,
multiple comorbidities, or both.
The most successful compliance with longterm exercise is most likely achieved by
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The rightsholder did not grant rights to

reproduce this item in electronic media.
For the missing item, see the original
print version of this publication.

FIGURE 1. The Activity Pyramid.

Copyright 1999 Park Nicollet HealthSource Park Nicollet Institute. Reprinted by permission.

identifying and overcoming barriers to activity, setting specific goals, recruiting

spouse/family support, and providing positive reinforcement. Although this can be time
consuming for family physicians, brief and
repeated counseling has been shown to be
highly effective.27 Unfortunately, according to
current Medicare guidelines, patient visits for
exercise promotion are not reimbursable
except as treatment for a specific disease or as
part of a separate G-code visit. Some evidence
exists, however, that exercise promotion is
more effective when included as a part of
counseling for a chronic disease.8
Overcoming Barriers to Exercise
Elderly patients face an array of personal,
socioeconomic, and environmental barriers
to exercise that are common to the general
population, as well as barriers that are unique
to the elderly (Table 6).
One half of older adults cite musculoskeletal discomfort or disability as a reason for not
exercising.28 Decreasing exercise intensity and
using a range of exercises can help avoid discomfort. It is often helpful to prescribe a
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range of exercise intensities that patients can

match to their energy or functional level on
any given day. Aquatic exercises limit the
weight-bearing load while providing cutaneous assistance to proprioception. Crosstraining, using a combination of activities,
balances the risks and benefits of weight- and
nonweight-bearing activities, uses a wider
range of muscle groups, decreases the risk of
overuse injury, and is less boring.
Habit is the single best predictor of inactivity across all age groups.29 Older persons often
must overcome a lifetime of ingrained behavior. Some older persons may be comfortable
in a role of dependence and feel threatened by
the charge of increased activity. Building on
previous activities can help overcome the
dominant influence of habit on activity levels.
For example, patients may be encouraged to
move the treadmill or stationary cycle in front
of the television, or consider having a low
step-aerobics box in the kitchen. An active
lifestyle also has health benefits comparable
with formal exercise regimens, but with improved rates of long-term compliance.30
Incorporating exercise into a prior routine
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TABLE 6

Common Barriers to Exercise in Older Adults

also makes it easier to remember, especially in

very old and cognitively impaired persons. Exercises should be simple; any new skills will
require specific instructions and repetition.
Self-efficacythe confidence in ones ability to carry out a planned behaviorhas been
shown to be a predictor of stair-climbing
ability, balance (i.e., risk of falling), and general functional decline in the elderly. In addition, it is also a strong predictor of exercise
participation, especially in women.31 Efficacy
scores increase across the stages of change
(i.e., patients become more confident of their
abilities as their level of activity increases).32
Patients with low self-efficacy should begin
exercising with easily accomplished goals and
receive frequent encouragement.
Despite the general lack of good exercise
role models for older persons on television
and through other media, societal norms are
not predictive of intention to exercise. Exercise
beliefs of family and close friends, however,
are important influences. Education of significant others regarding the safety and benefit of
exercise in older persons may be helpful.29
Additional Considerations
Physicians should match their advice to the
patients perception of how physical activity
may be beneficial (e.g., weight loss, improved
fitness, reduced coronary risk). Identify and
focus on individual beliefs rather than on
general health benefits. Help the patient set
specific goals and avoid the discouragement
of unrealistic expectations.
Understanding a patients personality is also
helpful. Whether patients are extroverted or
introverted will greatly affect their compliance
with a group exercise class versus a home program. As they become more functionally
dependent, they often have less influence over
when and how they exercise. This can be discouraging for those who have previously had a
strong internal locus of control.29
For most patients, any additional activity
beyond their current level will be beneficial.
Patients should be encouraged to add to exerFEBRUARY 1, 2002 / VOLUME 65, NUMBER 3

Barrier

Approach

Self-efficacy

Begin slowly with exercises that are easily accomplished;

advance gradually; provide frequent encouragement.

Attitude

Promote positive personal benefits of exercise; identify

enjoyable activities.

Discomfort

Vary intensity and range of exercise; employ crosstraining; start slowly; avoid overdoing.

Disability

Specialized exercises; consider personal trainer or

physical therapist.

Poor balance/ataxia

Assistive devices can increase safety as well as increase

exercise intensity.

Fear of injury

Balance and strength training initially; use of

appropriate clothing, equipment, and supervision;
start slowly.

Habit

Incorporate into daily routine; repeat encouragement;

promote active lifestyle.*

Subjective norms

Identify and recruit influential others; education of

patient and influential family/friends.

Fixed income

Walking and other simple exercises; use of

household items; promote active lifestyle.

Environmental factors Walk in the mall; use senior centers; promote active
(e.g., inclement
lifestyle.
weather)
Cognitive decline

Incorporate into daily routine; keep exercises simple.

Illness/fatigue

Use a range of exercises/intensities that patients can

match to their varying energy level.

*Examples of an active lifestyle include using a golf pull cart while golfing,
using a push mower, participating in activities such as stand and cast fishing or
gardening, and taking the stairs.

cises that they are already performing such as

climbing an additional flight of stairs or walking to a further light post or other distance
marker each week. More frail elderly patients
should increase intensity by adding hills,
hand weights, or arm movements rather than
increasing velocity.1
Finally, patients are more likely to do activities they consider enjoyable. They are also
more likely to resume pleasurable activities
following inevitable periods of relapse caused
by illness, hospitalization, or travel. Social
dancing, for example, is a great exercise and
most nursing homes use games as a proxy for
exercise. Patients can be helpful in designing
their own exercise programs.
The authors thank Thomas L. Schwenk, M.D., professor and chair, Department of Family Medicine,
University of Michigan, Ann Arbor, Mich., for his
help in the preparation of the manuscript.

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Exercise for the Elderly

The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.
17.
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